Shoulder girdle and elbow conditions

Baseline care for these conditions is acetaminophen or NSAIDs and physical therapy chosen by phase of healing; the entries below note what differs - special tests, surgery, bracing, or splinting.

• Acromioclavicular and sternoclavicular disorders

  • Occurs when falling on the adducted shoulder or when in collision with another individual, particularly during a sporting event
    • Grades of injury
      • Type I
        • A minor sprain of the acromioclavicular ligament
        • No radiographic displacement
        • No tear of the acromioclavicular or coracoclavicular ligament
      • Type II
        • A tear of the acromioclavicular ligament, but not the coracoclavicular ligaments
        • Less than 25% increase in the coracoclavicular interspace
      • Type III
        • Tears of both the acromioclavicular and coracoclavicular ligaments
        • 25% to 100% displacement of the clavicle
      • Type IV
        • Tears of both the acromioclavicular and coracoclavicular ligaments
        • Posterior displacement of the distal clavicle into the trapezius fascia

• Symptoms:

  • Pain at the top of the shoulder, which may worsen when moving the arm
  • Swelling, bruising, or tenderness over the joint
  • Limited range of motion in the shoulder
  • A bump or deformity where the clavicle or scapula has moved
  • A crunching or grinding sound when moving the arm
  • The collarbone may appear to move upward
  • The shoulder may appear to droop

• Diagnosis

  • Clinical presentation
  • Subjective statement of the mechanism of injury
  • X-ray

• Medical management

  • Surgery is rare due to the increased risk of deterioration it can have on the AC joint

• Physical therapy management

  • Sling during the acute phase to avoid shoulder elevation
  • Functional training and strengthening of muscles surrounding the joint
  • Manual therapy to the acromioclavicular or coracoclavicular ligament as appropriate

• Proximal humeral fracture

  • Occurs due to a fall on an outstretched arm and motor vehicle accident
    • Stable fractures that do not require surgery

• Symptoms

  • Intense shoulder pain
  • Swelling and bruising
  • Difficulty moving the arm

• Diagnosis:

  • Clinical presentation
  • Subjective statement
  • X-ray

• Physical therapy interventions

  • Early passive range of motion to decrease range of motion restrictions
  • Non-weight-bearing early per physician recommendations
  • Eventual active range of motion, strengthening, and coordination activities initiated once medically cleared

• Distal humeral fracture

  • Trauma causes a fracture at the distal humerus
    • Immediate attention must be given to whether a supracondylar fracture is due to the increased likelihood of neurovascular involvement
      • Radial nerve involvement associated with posterior type injuries may lead to damage of vascular structures, pulselessness, and/or paralysis
      • Ulnar nerve involvement associated with flexion type injuries may lead to paralysis and a loss of fine motor control in the hand
      • In children, it can cause malunion due to growth plate involvement
    • Lateral epicondyle fractures will require internal fixation (rod and screws implanted in arm) for adults, percutaneous removal pins for non-skeletally mature fractures, for proper alignment

• Symptoms

  • Severe pain in the elbow area that may radiate to the forearm and shoulder.
  • Pronounced swelling around the elbow joint.
  • The elbow may appear bent or twisted.

• Diagnosis

  • Clinical presentation
  • X-ray

• Medical management

  • Surgery for internal fixation

• Physical therapy management

  • Aid in the management of symptoms during the inflammatory phase
  • After surgical intervention and the time of immobilization has concluded, we will begin with mobility and strengthening

PTA role: If new neurovascular signs appear during treatment of a fracture or dislocation - pulselessness, new paresthesia, or paralysis distal to the injury - stop the intervention and notify the supervising PT immediately rather than modifying or progressing the plan of care. The PTA’s role is to collect data and report a change in status, not to make plan-of-care decisions.

• Thoracic outlet syndrome

  • Compression of the neurovascular bundle that includes the brachial plexus, sympathetic trunk, subclavian artery and vein, and phrenic and vagus nerves due to alteration in thoracic outlet size
  • Common areas of compression are:
    • Superior thoracic outlet
    • Scalene triangle
    • Between the clavicle and the first rib
    • Between the pectoralis minor and the thoracic wall

• Symptoms

  • Pain in the neck, shoulder, arm, or hand
  • Pain that worsens with certain activities, such as overhead reaching or holding objects
  • Numbness, tingling, or burning sensations in the arm, hand, or fingers
  • Symptoms may be worse at night or after prolonged activity
  • Weakness in the arm, hand, or grip
  • Swelling in the arm or hand
  • Coldness or cyanosis in the fingers

• Diagnosis

  • Clinical examination
    • Special tests
      • Adson’s test
      • Roos test
      • Wright test
      • Costoclavicular test
  • X-ray
  • MRI

• Medical management

  • Surgical removal of cervical rib as indicated
  • Surgical release of the scalenes as indicated

• Physical therapy management

  • Interventions vary based on the cause of thoracic outlet syndrome
  • Postural re-education
  • Joint mobility and strengthening as appropriate

Contrasting elbow conditions

• Medial epicondylitis

  • Inflammation of the pronator teres and the flexor carpi radialis tendons at the attachment of the medial epicondyle
    • Typically due to overuse in activities that require excessive pronation at the forearm
      • Commonly referred to as golfer’s elbow

• Symptoms

  • Pain on the inner side of the elbow, often radiating down the forearm
  • Pain that worsens with activities that involve gripping, twisting, or bending the wrist
  • Tenderness to the touch on the medial epicondyle
  • Weakness in the grip
  • Numbness or tingling in the ring and little fingers
  • Stiffness in the elbow

• Diagnosis

  • Clinical presentation
    • Special test
      • Medial epicondylitis (golfer’s elbow) test - pain at the medial epicondyle with passive forearm supination, elbow extension, and wrist extension

• Physical therapy management

  • Bracing may be indicated

• Lateral epicondylitis

  • Inflammation of the extensor carpi radialis brevis tendon at its attachment to the lateral epicondyle
    • Gradual onset occurring with repetitive wrist extension, resulting in overloading of the extensor carpi radialis

• Symptoms

  • Gradual onset of pain on the outer side of the elbow, often worse with gripping, twisting, or extending the wrist
  • Localized tenderness over the lateral epicondyle
  • May be mild swelling around the elbow.
  • Pain may spread from the elbow down the forearm or into the wrist.

• Diagnosis

  • Clinical presentation
    • Special tests
      • Cozen’s test

• Physical therapy management

  • Bracing may be indicated

• Ulnar collateral ligament injuries

  • Due to repetitive valgus stress to the medial elbow, causing stress to the ulnar collateral ligament

• Symptoms

  • Pain at the medial elbow at the insertion of the ligament
  • Paresthesias in the ulnar nerve distribution in the forearm and hand

• Diagnosis

  • Clinical presentation
    • Special test
      • Tinel test
      • Valgus elbow test
  • MRI

• Physical therapy management

  • Taping may be indicated

• Elbow dislocation

  • Caused by trauma to the elbow, causing misalignment from the anatomical position
    • Posterior dislocation is the most common
      • Posterolateral dislocation occurs as a result of hyperextension from a fall on an outstretched arm
      • Posterior dislocations commonly cause an avulsion fracture of the medial epicondyle
    • Complete dislocation will impact all of the following structures
      • Lateral collateral ligament, anterior capsule, brachialis muscle, wrist flexor muscles, and wrist extensor muscles

• Symptoms

  • Intense pain at the elbow joint, especially during movement
  • The elbow may appear visibly out of place, with the forearm at an unnatural angle
  • The elbow may feel loose or like it is going to give way.
  • Difficulty or inability to bend, straighten, or rotate the elbow.
  • Swelling and bruising around the elbow joint.

• Diagnosis

  • Clinical presentation
  • X-ray

• Medical management

  • Reduction of dislocation

• Physical therapy management

  • Stable elbow (easily reduced and stays in place) - initial immobilization followed by therapy to assist with regaining range of motion and strength
  • Unstable elbow (elbow continues to dislocate even after reduction) - surgery indicated